Provider Demographics
NPI:1841498839
Name:STAYWELL PEDIATRIC LLC
Entity type:Organization
Organization Name:STAYWELL PEDIATRIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ETKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-932-3227
Mailing Address - Street 1:365 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4217
Mailing Address - Country:US
Mailing Address - Phone:203-932-3227
Mailing Address - Fax:
Practice Address - Street 1:365 ELM ST
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4217
Practice Address - Country:US
Practice Address - Phone:203-932-3227
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT017752080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty